Hysteroscopy in the assessment of postmenopausal bleeding

Although postmenopausal bleeding (PMPB) is a frequent problem in clinical p ractice and as such has major clinical relevance, the management strategies are often quite different. This review, after an introduction describing t he various causes of PMPB, analyses in which order diagnostic procedures ar e indicated. There is much concern in decreasing the rate of invasive proce dures; this is possible with the aid of transvaginal ultrasound (TVS) which is very reliable in excluding endometrial cancer at a thickness of less th an or equal to4 mm. The vast majority of benign and malignant endometrial c hanges have an endometrial thickness of >4 mm. Since the specificity of TVS for a pathological finding at a thickness of >4 mm is low, other investiga tions are needed. Saline infusion sonohysterography (SIS), an easy compleme ntary tool to TVS, and office hysteroscopy seem to give the same results, t he first one being better accepted by the patients, the latter permitting b iopsies and resections to be performed at the same time. Anyway, in all the se cases a histological diagnosis is mandatory (endometrial biopsy/D&C/hyst eroscopic resection). In cases of persisting or recurrent PMPB, independent of the TVS result, a hysteroscopy (with biopsy and/or resection) is mandat ory.